Evaluation Chronic Diarrhea

8/11/2019 Evaluation Chronic Diarrhea

1/34

Evaluation of Chronic

Diarrhea1GREGORY JUCKETT, MD, MPH, and 2RUPAL TRIVEDI, MD1. A family medicine professor at West Virginia University, Morgantown, where he is a

International Travel Clinic

2. An assistant family medicine professor at West Virginia University, where she also provid

the StudentsCenter of Health

Presented by :

Chandra Kusuma

I 11108001


2/34

Definition

Chronic diarrhea is defined as a decreasein stool consistcontinuing for more than four weeks.


3/34

Categorization

Waterry diarrhea :

Osmotic (water retention due to poorly absorbed substances)

Secretory (reduced water absorption)

Functional (hypermotility)

Fatty diarrhea:

Malabsorption syndrome(damage to or loss of absorptive ability) Maldigestion(loss of digestive function)

Inflammatory or exudative diarrhea :

Inflammatory bowel disease (IBD)

Invasive infectious diseases

Neoplasia

Radiation collitis


4/34


5/34

Diagnosis


6/34

Medical History

A historyis the critical first step in diagnosis.

Stool volume, frequency, and consistency can help cadiarrhea, as previously mentioned.

A travel history is essential :

Travel to the tropicsvastly expands the list of diagnostic poss

no way rules out common causes.

Bloody diarrhea after a trip to Africamay still be ulcerative col

amebic dysentery.


7/34

Physical Examination

Recent weight loss or lymphadenopathy could result from chronic malignancy.

Eye findings, such as episcleritis or exophthalmia, suggest that thattributable to inflammatory bowel disease (IBD) and hyperthyroidism

Dermatitis herpetiformis, an itchy blistering rash, is found in 15 to

patients with celiac disease. An abdominal examination for scars (surgical causes of diarrhea),

(hypermotility), tenderness (infection and inflammation), and masshould be followed by rectal examination, including fecal occult blood t

Anal fistulae suggest Crohn disease.

A quick office anoscopy may detect ulcerations or impacted stool.


8/34

Laboratory Testing : Blood

Basic blood work may include :

complete blood count

albumin level

erythrocyte sedimentation rate liver function testing

thyroid-stimulating hormone level

electrolyte levels


9/34

Laboratory Testing : Stool

A minimal stool assessment should include a fecal leukocyfecal occult blood test, with further testing as indicated.

Fecal calprotectin, a neutrophil activity marker, is extremidentifying IBD.

Clostridium difficile stool toxin should be obtained for dihospitalization or antibiotic use.

A stool laxative screen (e.g., sodium, potassium, phosphate, sulfate, phenolphthalein, bisacodyl [Dulcolaxordered if abuse is suspected.

More specialized stool tests, including fecal fat analysis or afor fat, can be used to evaluate malabsorptive disorders.


10/34


A fecal pH test is quick and can be performed in the office if tnot taking antibiotics.

At least 0.5 mL of fecal matter is collected, and a strip of nitrazine pin the sample and compared with a color scale.

pH < 5.5

lactose intolerance. Fecal electrolyte levels can be used to distinguish secretory f

diarrhea.

Although fecal pH tests and fecal electrolyte levels areare often omittedfrom the initial workup.

Abnormal laboratory results help distinguish organic from functio


11/34


Travel risk factors might warrant :

a stool culture and sensitivity test

stool ova and parasite examination

Giardia and Cryptosporidium stool antigen tests

Giardia and Cryptosporidium infections are easily missed on rout

parasite examination, although stool acid-fast staininCryptosporidium.

Finally, sigmoidoscopy or colonoscopy is often required tspecific diagnosis.

Microscopic colitis can be diagnosed only by colon biopsy.

When it is necessary to distinguish between secretory categories of diarrhea, 24-hour stool collection can quantify stool


12/34

Diagnostic Approach

Physicians should determine if the diarrhea can be cawatery, fatty, or inflammatory, and then pick specific tests tomuch smaller differential diagnosis within each category.

Empiric therapy may be justified if a specific diagnosis suspected or resources are limited.

Life threatening conditions should be excluded.

A trial of metronidazole (Flagyl) for malabsorption in a traveler wougiardiasis.

An empiric trial of bile acid resins can help confirm bile acid malabsorption.

Follow-up should be performed in patients on em

because the patient may not improve, or may initially imprela se.


13/34


14/34


15/34

MAJOR CAUSES

Functional : Irritable bowel disease (IBS)

Inflammatory : Inflammatory bowel disease (IBD)

Secretory : Microscopic colitis

Fatty : Malabsorptive diarrhea

Primarily inflammatory : Chronic infection

Drug-induced

Endocrine

and

Other

Types

Of

Diarrhea


16/34

Irritable Bowel Syndrome (IBS)

The most common cause of functional diarrhea in the develo

IBS is a symptom complex :

Crampy abdominal pain accompanied by altered bowel habdiarrhea or constipation.

Usually watery diarrhea occurs while awake, often following m Discomfort is alleviated by defecation, and stool mucus is

half of patients.

Womenare diagnosed twice as often as men.

Alarmsymptoms such as nocturnal diarrhea, progressive pain, blood in the stoolsuggest another diagnosis.


17/34

Irritable Bowel Syndrome (IBS)

IBS is exacerbated by emotional stress or eating, but it may also b

to recent infection.

IBS symptoms subsequent to a bout of travelers diarrhea (p

IBS) may take months to resolve, despite a negative workup.

Screening for celiac disease and iron deficiency

recommended, but routine colonoscopy is not cost-effectivesymptoms are present.

Screening for celiac disease is justifiable because patients with

four times the incidence of celiac disease compared with

population.

All laboratory test results are normalin patients with IBS.


18/34


19/34

Inflammatory Bowel Disease (IBD)

IBD may manifest as ulcerative colitis or Crohn disease.

Both often involve blood and pus in the stool, with onset betand 40 years of age.

Early cases are often confused with IBS, but symptoms inevitaprogress.


20/34

Inflammatory Bowel Disease (IBD)

Early ulcerative colitis, distal colitis, and proctitis

result in episodes of rectal bleeding, diarrhea, pain, and tenesmus.

Moderate (left-sided) and severe (extensive) colitis are associatediarrhea, weight loss, fever, and anemia.

Crohn disease

typically causes an ileitis but later affects the entire gastrointebecome exudative.

Early symptoms can be subtle, leading to a long delay in diagnosis.

Abdominal pain, diarrhea, fever, perianal fistulae, and stools positivcommon, although bloody diarrhea is unusual.


21/34


22/34


23/34

Malabsorptive Diarrhea

Malabsorptive and maldigestive diarrhea result from impaabsorption and impaired digestive function, respectively.

Celiac disease (gluten-sensitive enteropathy), intestinmesenteric ischemia, small bowel bacterial overgrow

disease, and giardiasis can all cause loss of absorptive c

Absent pancreatic enzymes or bile acids can cause maldige

Classic symptoms include abdominal distention with large, floating, pale, fatty stools (steatorrhea) and weight


24/34


Celiac disease or sprue is small intestine malabsorption provok

(wheat) ingestion in genetically susceptible patients, often

descent.

Although predominantly a malabsorptive condition, celiac

also initially present as a watery diarrhea that may be confus Patients most commonly present with chronic diarrhea,

deficiency anemia, and weight loss, but this classic constella

absent.

In the United States, more than 2 million persons have celia

about one in 133 persons.


25/34


A positive celiac panel, typically consisting of immunoglobulin

gliadin, anti endomysium, and anti tissue transglutaminase a

usually followed by duodenal biopsy for confirmation.

IgA anti endomysium and anti tissue transglutaminase antib

much better accuracy than native gliadin antibodies (IgA

antibodies). The deamidated gliadin peptide antibody test is a more accu

generation IgA antigliadin antibody test but is not yet routinely

panels.

It should be noted that use of gluten-free diets before test

false-negative results, as can IgA deficiency or age younger than


26/34


Testing should be expanded to include all patients withchronic diarrhea, IBS, iron deficiency anemia, chronic fatloss, infertility, and elevated liver transaminase levels.

Symptomatic patients with type 1 diabetes mellitus

disease should be tested, because these conditions mato celiac disease.

Asymptomatic patients with a family history of celiac diseashould not be tested, although physicians should remdiscussing testing.


27/34

Chronic Infections

Most microbial gastrointestinal infections cause acute self-limited others persist, resulting in inflammation (invasive bacteria andoccasionally malabsorption (giardiasis).

A history of travel and antibiotic use is important.

Bacterial causes include Aeromonas, Campylobacter, C. difficile, Ple

Yersinia. Parasitic diarrhea may be caused by Cryptosporidium, Cyclospora

Giardia, Microsporida, and Strongyloides. Giardia, the most common odiagnosed with fecal antigen testing.

Brainerd diarrhea is an epidemic form of long-lasting secretory diarrwith consumption of unpasteurized milk or contaminated water. T

infectious agent has never been identified


28/34

Chronic Infections

C. difficile, the cause of pseudomembranous colitis, hasa major infection in U.S. hospitals.

This gram-positive anaerobic bacillus is easily spread throughspores, rapidly colonizing the colon following antibiotic thera

A history of using fluoroquinolones, clindamycin, pcephalosporins in the past three months is often associated.

Approximately 3 percent of healthy adults may be ascarriers, but this increases to at least 40 percent in hospitalize


29/34

Chronic Infections

Proton pump inhibitors and IBD further increase the risk oinfection.

Older, sicker patients are more likely to develop clinical dis

Because IBD and C. difficile infection produce similar symnecessary to exclude the latter in ill patients.


30/34

Drug-induced

Although C. difficile infection is induced by antibiotics, drugs

cause diarrhea.

Laxatives, antacids, proton pump inhibitors, and antineoplasti

medications that can lead to diarrhea.

Laxative or antacid abuse is a common cause.

Diarrhea may be osmotic (from magnesium, phosphates, sulfates

secretory following use of stimulant laxatives.

Symptoms resolve when the offending agent is eliminated


31/34


32/34


33/34

Endocrine and Other Types OfDiarrhea

Endocrine causes of chronic secretory diarrhea include Addcarcinoid tumors, vipoma, gastrinoma (Zollinger-Ellison syndmastocytosis.

Hyperthyroidism increases motility.

Serum peptide concentrations (e.g., gastrin, calcitonin,intestinal peptide) and urinary histamine level should be obtainethese conditions are suspected.

Neoplastic diarrhea is associated with colon carcinadenocarcinoma, and lymphoma.


34/34

Evaluation Chronic Diarrhea

Documents

Transcript of Evaluation Chronic Diarrhea